Location and Control of Local Disease Predict Overall Survival and Distant Metastases Free Survival in Patients with Ipsilateral Breast Tumor Recurrence after Breast Conserving Therapy for Stage I/II Breast Cancer
Reviewer: Voika BarAd, MD
Abramson Cancer Center of the University of Pennsylvania
Last Modified: October 17, 2005
Presenter: Y. Chen
Presenter's Affiliation: Radiation Oncology, Massachusetts General Hospital, Boston, MA
Type of Session: Scientific
- The best approach to ipsilateral breast tumor recurrence after breast conserving surgery and radiation has not been established.
- Studies have shown that patients with ipsilateral breast tumor recurrence have a higher risk of distant failure and poorer survival.
- The outside-of-tumor bed recurrences appear to have better prognosis than in-tumor-bed recurrences. This study evaluates the pattern and prognosis of ipsilateral breast tumor recurrence, in patients treated with breast conserving therapy.
Materials and Methods
- 1280 patients with early stage invasive breast cancer were treated with breast conserving therapy between 1980- 2000.
- The median age was 59.7 years (32-78).
- The median follow up was 9 years (12- 220 months).
- The median dose of irradiation was 60 Gy (50 Gy whole breast and 10 Gy tumor bed boost).
- The ipsilateral breast tumor recurrences were detected by mammography, physical examination or both.
- 72 patients developed ipsilateral breast tumor recurrence; 8 patients had concurrently distant metastasis; 64 patients only had isolated local recurrence.
- From 64 patients with only ipsilateral breast tumor recurrence 52 patients (81%) had in-tumor-bed recurrences and 12 patients (19%) had outside-of tumor bed recurrences.
- The rate of in-tumor-bed recurrences was 2.5%, 4%, 6% compared with outside-of-tumor bed recurrences 0.3%, 1.3%, 2% at 5, 10, and 15 years.
- Mean time to outside-of-tumor bed recurrences was 67 months, vs. a shorter time to in-tumor-bed recurrences of 56 months.
- Median survival time after in-tumor-bed recurrences was only 39 months, compared to 60 months after outside-of-tumor bed recurrences.
- The entire cohort has overall survival of 92%, 81%, and 73% at 5, 10, 15 years.
- Disease free survival was 87.5%, 74%, 65% at 5, 10, 15 years.
- Distant metastasis free survival was 87.5%, 74% and 65% at 5, 10, 15 years.
- Distant metastasis free survival was 96.8% for mammography detected recurrences vs 52% in clinically detected local recurrences.
- Patients whose ipsilateral breast tumor recurrence was controlled with salvage therapy had 84.6% 10 years survival, compared with 21.4% for persistent local disease and 6.7% for subsequent distant metastases.
- A multivariate analysis shown that the short interval to ipsilateral breast tumor recurrence < 3 years and clinically symptomatic recurrence were associated with poorer prognosis.
- On multivariate analysis, the site of recurrence and surgical salvage were favorable prognostic factors.
- Local failure within the primary tumor bed occurs sooner after breast conserving therapy and results in significantly lower overall survival and distant metastasis free survival.
- The outside-of-tumor bed recurrences were rare during the first year after breast conserving therapy.
- This study showed that the control of local failure affects overall survival time after recurrence.
- It is important to distinguish true tumor bed recurrence from outside of tumor recurrence for more accurate assessment of prognosis and the choice of treatment in patients with ipsilateral breast tumor recurrence.
- Breast conservation therapy undoubtedly represents substantial progress for a better quality of life for women with early stage breast cancer.
- However lumpectomy is associated with a substantial proportion, approximately 10-20%, of local recurrence in long- term follow-up studies even after accounting for postoperative radiotherapy.
- The risk of failure includes margin status, young age, and extensive intraductal component.
- This study, and another retrospective study, demonstrated that control of the local failure dramatically affects survival time after recurrence.
- Selecting women for breast- conserving therapy and achieving margin control can reduce ispsilateral failures and in this way the long term outcome in patients with early breast cancer.